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A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
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A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
- A. High in carbohydrates.
- B. High in fiber.
- C. Low in residue.
- D. Low in fat.
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora. Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
- A. To limit the amount of bleeding and clots from the surgical site.
- B. To eliminate the need for wound irrigations.
- C. To prevent drainage from accumulating in the wound.
- D. To provide a means for medication administration.
Correct Answer: C
Rationale: Rationale:
The correct answer is C: To prevent drainage from accumulating in the wound. A Jackson-Pratt drain is used to remove excess fluids (such as blood or serous fluid) from a surgical site to prevent accumulation, which can lead to infection or delayed healing. The drain creates negative pressure, allowing drainage to be collected in a bulb or reservoir outside the body. This promotes wound healing by preventing the buildup of fluid.
Incorrect choices:
A: To limit bleeding - While a JP drain may indirectly help limit bleeding by removing excess fluid, its primary purpose is to prevent fluid accumulation.
B: To eliminate wound irrigations - JP drains do not eliminate the need for wound irrigations; they are used for drainage removal.
D: Medication administration - JP drains do not provide a means for medication administration; they are specifically for drainage removal.
A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 18/min.
- B. Blood pressure 102/66 mm Hg.
- C. Yellow-green drainage on the surgical incision.
- D. Straw-colored urine from an indwelling urinary catheter.
Correct Answer: C
Rationale: The correct answer is C because yellow-green drainage on the surgical incision can indicate an infection, which is a critical postoperative complication that requires immediate attention from the provider. This finding suggests the presence of pus or other infectious material in the wound, increasing the risk of further complications like wound dehiscence or systemic infection. Reporting this to the provider promptly allows for timely intervention such as wound exploration, debridement, and initiation of appropriate antibiotics.
The other choices are not as concerning in the immediate postoperative period:
A: Respiratory rate within normal range
B: Blood pressure within normal range
D: Straw-colored urine is expected from an indwelling urinary catheter, indicating adequate kidney function and hydration.
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
- A. Insert a nasogastric (NG) tube.
- B. Ask the client about the precipitating events.
- C. Obtain vital signs.
- D. Complete a head-to-toe assessment.
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice A) or completing a head-to-toe assessment (choice D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice B) may provide important information but is not as urgent as assessing vital signs in this critical situation.